Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> HAZARDOUS WASTE TANK CLOSURE CERTIFICATION. <br /> a o of <br /> L FACILITY IDENTIFICATION <br /> BUSIWSNAME(Same nPACturvxwaaQ-r DBA_Doing aaimemAs) 3 FACILITY ID# RrW <br /> t <br /> TANK nWNFR NA MV <br /> PER IT/SE CES <br /> TANK OWNER ADDRESS d74t <br /> (� L <br /> TANK OWNER CITY ®��� c%► STAT$ ► ZIP CODE <br /> II, TANK CLOSURE INFORMATION <br /> Tank on # Concentration of Flammable Vapor(Attach additional mptm <br /> Concentration of Oxygen <br /> ofthis peso for mom than <br /> TANK . duec uaca) Top Center Bottom Top Center Bottom <br /> INFERIOR /y 745 746a 7460 <br /> ATMOSPHERE I — 7466 747a 7476 / 747c <br /> READINGS 2 ® 48 f/ 749a 7496 7 9c / l <br /> 750a ! 7506 1 750c <br /> 3 751 7521t 7526 752c / <br /> 7 a 753b 753c <br /> III. CERTIFICATION <br /> On examination of-the tank,I certify the tank is visually free from product,sludge,scale(thin,flaky residual of tank contents),rinseate and debris. I further certify!that <br /> the information provided It n is true and accurate to the best of my knowledge. <br /> SIGNATURE OFC TIFIFR STATUS OR AFFILIATION OF CERTIFYING PERSON <br /> Z..�/�. Certifier is a representative of the CUPA,authorized agency,or LIA: 7� <br /> OF CE TIFiER (Print) ) 7$4 ❑ Yes �No ' <br /> Name of CUPA,authorized agency,or LIA: 761 <br /> TITLE OF C TIFIER 755 <br /> If certifier Is other than CUPA/LIA check appropriate box below: 762 <br /> ADDRES 75 <br /> }� ❑ a. Certified Industrial Hygienist(CIH) <br /> �/ \ ❑ b. Certified Safety Professional(CSP) <br /> CITY r 757 4 c. Certified MarineChemist(CMC) <br /> l— ❑ d. Registered Environmental Health Specialist(REHS) <br /> PHONE 7 <br /> 11e. Professional Engineer(PE) <br /> 759 <br /> / � / ❑ L Class-II Registered Envirownentai Assessor <br /> DATE CEBTIEII A'I©I TIME . Contractors'State License Board licensed contractor(with hazardous <br /> substance removal certification) <br /> TANK PREVIOUSLY HELD FLAMMABLE OR COMBUSTIBLE MATERIALS 763 <br /> (If ycl,the tank interior atmosphere shall be rodtockod with a cvmbustiblo Sac indicator prior to work urns conducted on the tank) <br /> CERTIFIER-S TANK MANAGEMENT INSTRUCTIONS FOR SCRAP DEALER,DISPOSAL FACILITY,ETC; Yes ® No <br /> 764 <br /> A oopy.of this cettificato shall accompany the rade to the recycling/disposal faciliry and be provided to tho CUPA. If there is uo CUPA,copies shall be submitted to the LIA and authorized <br /> a ea owner/o t of the n s stem removal contractor and the ro clia /tii sat facih' , <br /> 2— Formerly DTSC 1249(61M) <br />